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PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. Module 5 Depression in primary care. Introduction to Primary Care: a course of the Center of Post Graduate Studies i n FM Dr Wedad bardisi. Objectives. Know thhe prevalence of depression in KSA

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PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

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  1. PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 Module 5 Depression in primary care Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM Dr Wedadbardisi

  2. Objectives • Know thhe prevalence of depression in KSA • know the size of the problem in primary health care. • Encourage trainee to use DSM IV diagnostic criteria. • Encourage recognition of depression and determine its cause & classification. • know proper history taking and physical examination. • know evidence based management options. • Know methods of screening for depression in family practice. • know how to do proper follow up. • know when to refer.

  3. Size Of The Problem • The World Health Organization ranks major depression among the most burdensome diseases in the world • Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major depression, 3 to 5 percent for dysthymia, and 10 percent for minor depression. • About 70%-80% of all psychiatric patients had been firstly visit their Family physician or primary care doctors before seen by psychiatrist. • Depression often Goes Undetected

  4. Prevalence • Depression symptoms are very common. 13 to 20% of the population being affected at any one time. • In KSA the prevalence is similar to that of world wide i.e 20%. • The prevalence of major depression is estimated at 10 to 20 percent in patients with medical illnesses such as diabetes and heart disease. • Women are affected more than men.

  5. Major Depressive Disorder(MDD) • Major depression is a relapsing, remitting illness in most patients. • Recurrence rate is 40% following the first episode over two years. • After two episodes, the risk of recurrence within five years is approximately 75 percent. • 10 to 30 % of patients treated for a major depressive episode will have an incomplete recovery, with persistent symptoms or dysthymia

  6. Depression if untreated or inadequately treated , is a disease associated with high mortality, morbidity and economic costs, and danger serious disorder 15% of the patient commit suicide. • Many patients find a diagnosis of depression difficult to accept

  7. Suicide rate by age and gender. 2004 data compiled from CDC. The mean suicide rate for the entire population was 12.8/100,000/year.

  8. Classification according to DSM IV • Major depressive disorder ( Unipolar). • Dysthymic disorder (mild sepression)- At least 2 years of lower-level depressive symptoms • Bipolar depression - A major depressive episode arises in a patient with a history of hypomanic, manic, or mixed episodes • Adjustmentdisorder - Emotional or behavioral symptoms that arise in response to an identifiable stressor and that cease once the stressor has terminated

  9. Predisposing Factors • (1) Genetic & familial factors. • (2) Impaired social supports • (3) Loneliness. • (4) Bereavement. • (5) Negative life events. • (6) Childhood abuse and neglect. • (7) postpartum. • As well as cumulative load of stressors like: • - Unhappy marriage. • - Problems at work. • - Unsatisfactory housing. • - Lack of employment. • - Lack of confiding relationship.

  10. OTHER ILLNESSES CAN CAUSE DEPRESSIVE SYMPTOMS

  11. Clinical Picture MOOD SYMPTOMS PSYCOLOGICAL SYMPTOMS • Sad • Depressed • anhedonia • Greif • Suicidal Ideas. • Guilt Feeling • Low Self Esteem • Lack Of Concentration CATEGORIES OF DEPRESSIVE SYMPTOMPS SOMATIC SYMPTOMS BEHAVIOURAL SYMOPTOMS • Disturbed sleep pattern. • Appetite change. • Weight change. • Decreased sexual drive. • Loss of energy, fatigue. • Retardation • Agitation. • Negligence Of Work • Negligence Of Social Activity

  12. MOST COMMON PRESENTING SYPMTOMS • Sleep disturbance. • Fatigue • Pain. • Anxiety. • Irritability • Gastrointestinal disorders.

  13. Unexplained Somatic symptoms: C.V.S • Palpitation • Pseudoanginal pain. Respiratory : • Dyspnea • Hyperventilation . Gastrointestinal • Vomiting • Bowel disturbance • Colics Musculosklettal • Low backache Genitourinary • Frequency micurition • Impotence Vs premature ejaculation • Dysparonia • frigidity

  14. Diagnostic criteria for major depressive episode (adapted from DSM-IV-TR17 ) • At least 5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least 1 of the symptoms is either #1 or #2. • Depressed mood most of the day, nearly every day • Markedly diminished interest or pleasure in all, or almost all, activities most of the day ( TWO SCREENING QUESTIONS) • Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate, or indecisiveness • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

  15. Screening of depression in primary care • Key symptoms: • • persistent sadness or low mood; and/or • • loss of interests or pleasure • • fatigue or low energy. • At least one of these, most days, most of the time for at least 2 weeks. • NICE Guideline – depression (amended April 2007) 61

  16. If any of above present, ask about associated symptoms: • disturbed sleep • poor concentration or indecisiveness • low self-confidence • poor or increased appetite • suicidal thoughts or acts • agitation or slowing of movements guilt or self-blame

  17. Then ask about past, family history, associated disability and availability of social support 1. Factors that favour general advice and watchful waiting: • four or fewer of the above symptoms • no past or family history • social support available • symptoms intermittent, or less than 2 weeks duration • not actively suicidal • little associated disability.

  18. 2-Factors that favour more active treatment in primary care: • • five or more symptoms • • past history or family history of depression • • low social support • • suicidal thoughts • • associated social disability.

  19. 3. Factors that favour referral to mental health professionals: • • poor or incomplete response to two interventions • • recurrent episode within 1 year of last one • • patient or relatives request referral • • self-neglect.

  20. 4-Factors that favour urgent referral to a psychiatrist: • • actively suicidal ideas or plans • • psychotic symptoms • • severe agitation accompanying severe (more than 10) symptoms • • severe self-neglect.

  21. ICD-10 definitions • Mild depression: four symptoms • Moderate depression: five or six symptoms • Severe depression: seven or more symptoms, with or without psychotic features • NICE Guideline – depression (amended April 2007)

  22. Physical Examination • The physical examination of a patient with depression may reveal evidence of malnutrition or poor self-care. •  The mental status examination is central to the diagnosis of depression, and includes the following components: • Appearance and behavior. • Mood and affect. • Thought processes and speech. • Thought content • Cognition.

  23. Dysthymia (mild depression) Dysthymia: is a chronic mood disorder with a duration of at least 2 years (1 year in adolescents and children). • It is manifested as depressed mood accompanied by at least 2 of the following symptoms: • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration • Difficulty making decisions • Feelings of hopelessness

  24. Bipolar affective disorderDSM IV Manic episodes are characterized by the following symptoms: At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansiveness OR Hypomanic episodes are characterized by the following: An elevated, expansive, or irritable mood of at least 4 days' duration Alternating with major depressive episodes. .

  25. Adjustment disorderDSM IV • A "maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within 3 months after onset of that stressor.. The condition is: • Acute: If the disturbance lasts less than 6 months. • Chronic: If the disturbance lasts 6 months or longer.

  26. A typical presentation • In the primary care setting, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or change in weight. • Patients may complain more of irritability than of sadness or low mood. • Elderly persons may present with confusion or a general decline in functioning. • Children with major depressive disorder may also present with irritability, decline in school performance, or social withdrawal

  27. Assessment of suicidal ideation • Assessment for the presence of suicidal ideation is of paramount importance in all depressed patients. • Evaluation for suicide risk should include assessment of the following : • Presence of suicidal or homicidal ideation, intent, or plan • Access to means for suicide and the lethality of those means • Presence of psychotic symptoms, command hallucinations, or severe anxiety • Presence of alcohol or substance use • History and seriousness of previous attempts • Family history of or recent exposure to suicide • Evaluation in an emergency department and/or hospitalization should be considered for patients at significant risk of suicide.

  28. Management • A wide range of effective treatments is available for major depressive disorder. • Brief psychotherapy (eg, cognitive behavioral therapy, • interpersonal therapy). • Patients who do not respond after 12 weeks of initial psychotherapy should be started on an antidepressant. • However, the combined approach generally provides the patient with the quickest and most sustained response

  29. Pharmacological Treatment

  30. PHARMACOLOGICAL TREATMENT……… • Tricyclic antidepressant.(side effects are problem) • MAOI ( not used frequently) • SSRI

  31. :Side effects of TCA • Antimuscarinic side effects like: • Dry mouth, blurring of vision, urinary retention, sweating and constipation. • Postural hypotension . • Arrhythmia. • Convulsion • Increase appetite and weight gain

  32. Examples of TCA

  33. MAOI : Less frequently used because of dangerous interactions with foods and drugs. Side effects: Postural hypotension, drwsiness, headache, dry mouth costipation, oedematremors,hypereflexia, sexual disturbances, and blood and liver diorders. • e.gPhenelzine ( Nadril) : dose 15 mg 3 times daily , max.30mg daily

  34. The SSRIs All share several characteristics

  35. Examples of SSRI

  36. St. John's wort (Hypericum perforatum) • St. John's wort is considered a first-line antidepressant in some countries • Used to treat of mild-to-moderate depressive symptoms. • It acts as an SSRI. • The dose is 300 mg 3 times a day with meals to prevent GI upset. • side effects include: • gastrointestinal upset, increased anxiety, minor palpitations, fatigue, restlessness, dry mouth, headache, and increased depression.

  37. Clinical course Is classified using six categories: • Response — Significant reduction (usually >50 percent) of depressive symptoms during the acute treatment phase. • Remission — A period of ≥2 weeks and <2 months with no clinically significant depressive symptoms. • Partial remission — A period of ≥2 weeks and <2 months with one or more clinically significant depressive symptom(s). • Relapse — An episode of depression during the period of remission. • Recovery — A asymptomatic period of more than two months. • Recurrence — The emergence of symptoms of MDD during the period of recovery (a new episode).

  38. Referral • Referral to a psychiatrist or to a treatment centre should be considered in the following circumstances: • 1- If the patient is expressing a suicidal intent or if there was a recent suicide attempt • 2- If the patient is elderly, confused and presentation of the history is unclear • 3- If the presenting symptoms of the disorder are severe, e.g., severe weight loss or weight gain , severe physical damage from drinking, severe withdrawal symptoms, several unsuccessful attempts to quit drinking. • 4- If the diagnosis is not clear • 5- If the treatment fails after the patient has received an appropriate medication trial • 6- If the management requires hospitalization or intensive treatment e.g. extreme hostility, aggression or homicide • 7- If there is one of comorbidity with severe physical or other mental disorders

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